Final - Thermal Injuries Flashcards
7 major functions of the skin
- temperature regulation
- protection
- sensation
- excretion
- immunity
- blood reservoir
- Vitamin D synthesis
Pathophysiology of Burns
When someone gets burned, their skin absorbs heat. This causes tissue coagulation –> broken down into 3 zones:
coagulation, stasis, hyperemia
Pathophysiology of Burns
When someone gets burned, their skin absorbs heat. This causes tissue coagulation –> broken down into 3 zones:
coagulation, stasis, hyperemia
Zone of Coagulation
- Occurs at the point of maximum damage
- Irreversible tissue loss due to coagulation of the constituent proteins
Zone of Stasis
- Surrounding zone is stasis is characterized by decreased tissue perfusion
- tissue is potentially salvageable
- main aim of burns resuscitation is to increase tissue perfusion here and prevent any damage from becoming irreversible
- additional insults (prolonged hypotension, infection, edema, etc) can convert this zone into an area of complete tissue loss
Zone of Hyperemia
- outermost zone
- perfusion is increased
- tissue here will recover unless there is severe sepsis or prolonged hypoperfusion
- these three zones of a burn are three dimensional, and loss of tissue in the zone of stasis will lead to the wound deepening as well as widening
Superficial/First Degree Burn
Epidermis Injured
*bad sunburn
Partial Thickness/Second Degree Burn
- Superficial partial-thickness: superficial dermis injured
- Deep partial-thickness: deep dermis damaged with hair follicles and sweat glands intact
Full Thickness/ Third Degree Burn
Entire dermis is injured
Full Thickness/ Fourth Degree Burn
Muscle, bone injured
Appearance of First Degree/Superficial Burns
- pink or red
- may have edema
- no blisters
- blanches
- skin/sensation intact
First Degree Burn Healing Time
3-5 days through epithelization
Second Degree/Superficial Partial Thickness Appearance
- Pink or red
- edema present
- moist with blisters
- blanches with quick refill
- sensation intact
Second Degree/Superficial Partial Thickness Healing
1-2 weeks through epithelization
changes in pigmentation
Second Degree/Deep Partial Thickness Appearance
- Pink or ivory
- Dry with blisters
- May have no light touch, decreased pinprick
- Can feel deep pressure
- Hair easily removed
- Blanch with slow refill
Second Degree/Deep Partial Thickness Healing
2-3 weeks with epithelization
will likely need graft
scar formation likely
Third or Fourth Degree/ Full Thickness Appearance
- white, red, brown, black
- dry, may have blisters
- no blanching
- no sensation
Third or Fourth Degree/ Full Thickness Healing
> 3 weeks with granulation and epithelization
usually requires surgery
Mechanisms of Burns
- Thermal
- Electrical
- Chemical
- UV and Radiation
Most common to least common thermal burns
scald
flame
flash
contact
What does severity of thermal burns depend on?
- location of burn, temperature of the source, and duration of the contact
Characteristic of electrical burns
- entrance and exit wounds
- muscles, tissues, nerves, and bones act as conductors
- nerve damage common
- arc wounds
Explain the varying severity of electrical burns
- smaller more distal areas are damaged the most severely leading to high amputation incidence
- severity is related to duration of contact, voltage, and the pathway, resistance, and amperage of the current through the body tissues
Chemical burns can be with or without what?
associated thermal injury
what does the severity of chemical burns depend on?
- type of chemical
- concentration of chemical
- duration of contact
- mechanism of action
UV and radiation burns
- can be with or without thermal injury
- most often happens after radiation treatment with cancer
- often referred to as acute radiation syndrome
Rule of Nines
- TBSA tells you about the change of survival
- quick and easy to use (especially in emergencies)
- modifications can be used if the entire body part is not burned
Do infants and children use the same rule of nines as adults?
no
Lund and Bower Formula
- more exact and accurate than rule of nines
- better for irregularly shaped burns
- ABA prefers the use of this method in conjunction with palmar method where the patient’s palm is 1% of TBSA
No matter what measurement tool you use, what should you take into account?
burns are dynamic wounds which means that accurate measurement and classifications of the burn can not be made until the burn is completely developed
Complications of Thermal Burns
- Cardiovascular: increased generalized body edema, increased HR, decreased SV and CO
- Renal and GI issues
- Respiratory Issues
Complications in electrical burns
- cardiovascular (EKG for all patients)
- neurological issues
- orthopedic
- damage to organs, cataracts, tympanic membrane rupture, anxiety, depression, PTSD
Those with documented LOC or arrhythmia following an electrical burn should do what?
be admitted for telemetry monitoring
Complications of chemical burns
- System toxicity due to subcutaneous absorption (liver toxicity, renal dysfunction)
- Pulmonary complications (bronchospasm, edema, epithelial sloughing)
Complications of UV and Radiation Burns
- GI
- Hematologic
- Vascular (endothelium destruction)
What hematologic complications are associated with UV and radiation burns?
- Pancytopenia: decreased RBC, WBC, platelets
- Granulocytopenia: decreased granular leukocytes
- Thrombocytopenia: decreased platelets
- Hemorrhage
Complications of ALL burns
- marked hypermetabolism
- skeletal muscle catabolism
- decreased pulmonary function
- depression, stress, anxiety
- PTSD, nightmares, insomnia
How much is resting energy expenditure following a burn increased by?
20-100%
remains increased for months to years
3 phases of wound healing
- Inflammatory phase: 3-5 days
- Proliferative phase: 2-3 weeks
- Maturation phase: >3 weeks
Inflammatory phase of healing
3-5 days
inflammation begins, fibroblasts start to travel to the wound, rid wound of foreign tissue
proliferative phase
2-3 weeks
fibroblasts reach the wound, angiogenesis and granulation occur, collagen is made for the wound, wound contractures begin to form
Resuscitative Phase
- monitoring for inhalation injury and carbon monoxide poising
- fluid resuscitation (burn shock)
- infection control
- body temperature and maintenance (hypothermia)
- pain management
initial care during resuscitative phase
- address burns with wound care, topical agents, and debridement if necessary
- escharotomy and fasciotomy
Reparative phase
- scarring: normotrophic, hypertrophic, keloid
- wounds that take more than 21 days to heal are 78% more likely to form hypertrophic and keloid scars
what populations are keloid scars more common in?
- young women
- people with darker pigmented skin
Surgical procedures during reparative phase
- eschar is dead dermis that is attached to the wound bed and prevents normal wound healing
- excision is the removal of eschar to promote wound closure
Why is grafting performed during the reparative phase?
to optimize functioning
PT considerations for grafting
- WB restrictions
- specific protocol for that patient
- is the graft across or close to a joint?
- donor site is often more painful than actual burn
Autograft
- graft patients own skin from a donor site
- AROM can start POD 5
homograft/allograft
- graft cadaver skin
- temporary to help with healing and protection from infection
- ROM can start POD 1
Heterograft/Zenograft
- graft from pig skin
- temporary
- ROM can start POD 1
Skin Substitutes - Biobrane
- temporary –> 1-2 weeks
- used on freshly debreided partial thickness wounds and donor sites
- can be protection for an autograft
Skin Substitutes- Integra
- temporary coverage of full thickness or deep partial thickness wounds
- will eventually be removed and replaced with thin autografts one blood supply is adequate
Non-surgical procedures
- wound debridement by PT, nurse, physician
- priority is maintaining moist healing environment, maximizing granulation and epithelization, and minimizing tissue trauma and infection
- benefits of electric stimulation on reducing surface area of wounds
What occurs after wounds have healed and swelling had decreased?
pt might receive compression garments for keloid scarring
Mortality with burn population
- higher TBSA = higher risk of death
- ages 75 and older
- increased BMI
- presence of comorbidities
- precent of inhalation injuries
how does gender affect mortality in burn population?
- hormonal levels change your cell mediated immune response
- increased with women between ages of 13-39 and 50-59
- elderly women even if they have less severe injuries than male counter parts
Infection control for burn population
- scrubs
- no lab jacket
- gowns, masks, gloves
- follow hand washing procedures
patients that need to be seen in specialized setting
- burn involving face, hands, feet, eyes, ears or perineum
- electrical burn involving 110-220 volts or higher
- 20% TBSA burn
- 10% in child or older adult
- > 5% full thickness burn
Taking a history
- does the story make sense?
- does it change?
- possible signs of abuse?
- get patients story and families version if possible
- get in contrast with social worker if needed
- document everything
Objective assessment
- level of consciousness
- pain at rest, with PROM, AAROM, and AROM
- location of grafts, dressings, splints, garments
- presence and location of edema
- current positioning
- vitals
- MMT if possible
- sensation
are debridement, fasciotomy, heterografts, and synthetic dressings contraindications for exercise?
no!
skin grafts over joint might halt PT in a particular area for a couple of days
Treatment during Acute Phase - ICU
- position changes
- edema control (compression sleeves or pumps using <50 mmhg)
- pts should receive therapy 2x/day even if they are sedated
Therex in ICU
- Short duration, high frequency
- AROM > AAROM > PROM
- sitting endurance, standing endurance, gait
- spending time in chair increases alertness, encourages WBing, and facilities pulmonary function
- try to start 1.5-2 hrs out of bed
- deep breathing exercises
How to manage pain in acute phase
- schedule therapy sessions for when medication is most effective
- in unconscious pt’s, monitor vitals for pain
ROM of shoulder and elbow/forearm during acute phase
- shoulder : 90 degrees abduction, ER, 10 degrees horizontal adduction
- elbow/forearm: extension with supination
Role of PT after autograft
- pre-op ROM, stretch, function
- re-start gentle ROM day 5 (dependent on graft adherence)
- splints may continue to be used for night/sleeping
- progressive stretching to end range PROM as needed by day 7
If a graft has not “take” by day 7-10,
it is considered graft loss
Gait in the ICU
- should be done within 48 hrs and when medically stable
- less DVTs and PEs
- shorter hospital stays
- pt can ambulate immediately after graft surgery as long as compression is applied
- be careful of gait belt placement
Contraindications of gait in acute phase
- fractures in LE
- pre injury inability to walk
- wounds >300 cm might have to wait 3-5 days
- overriding psychiatric conditions
- medical status prohibiting mobilization
- plantar surface of foot is grafted
mobility training during acute phase
- consider hand placement and location of burn
- ensure dressings remain intact
- avoid shearing forces over burned area
- compression and/or muscle pumping of dependent limbs
- monitor vitals, especially burns >15 % TBSA
- gait belt may or may not be appropriate
- may need additional assistance in ICU
Treatment in subacute inpatient phase
- continue working on ROM
- stretching with low force and long duration
- repeated gait assessments to detect contractures at knee or hip
- continue deep breathing for respiratory health and stress/pain control
long term care- outpatient
- pt needs to be reassessed after d/c
- goals of rehab will change
- full functional ROM and increasing tolerance for ambulation
- 30 mins aerobic exercise 3-5 times per week
- 30 mins strengthening activities 2-3 nonconsecutive days/week
- 6-12 weeks of OP therapy indicated
- scar massage 3x/day for 5 min
- desensitization
- pain control
- discharge with HEP
about how many patient return to their pre-burn environment?
95%
Compression garments
- continues to be standard
- 30-45 mmhg
- can flatten and improve scar by 92%
- decreases hydration of scar, reduces neovascularization, and accelerated the remission phase of the post-burn reparative process
how long does a pt wear compression garments?
2+ years, weaning into wearing it for 23 hrs a day
silicone compression garments
watch for maceration and contact dermatitis
